Poliomyelitis

Definition:
It is an acute viral infection of human, which tends to localize in
the motor neurons of the central nervous system specially the spinal cord
and brain stem, causing a lower motor neuron type of paralysis without
sensory loss. The infant gets sub-clinical infection; the older child gets
paralysis while the adult often dies because of the extensive paralysis.
Virology:
Three types of polioviruses are known since 1951:
- Type 1 Brunhilde: It is the commonest poliovirus in !gypt.
- Type " Lansing.
- Type # Leon.
The child may be attac$ed by the three types of polioviruses
successively, as infection by one virus does not immune the child against
the other two types. The virus can be isolated from the pharyngeal
secretions one wee$ before and two wee$s after the onset of clinical
infection. It can be found in the stool for a month or longer after the
infection started.
History:
- It has been first occurred in the time of the ancient !gyptians.
- In 1%&', Underwood was the first to describe poliomyelitis.
- In 1&#(, the first epidemic of poliomyelitis occurred.
- In 1&)), Duchenne descried the pathology process in poliomyelitis.
- In 1'*&, Landstener transmitted poliomyelitis to a mon$ey.
- In 1')1, the three $nown polioviruses were isolated and identified.
- In 1')&, a!ine vaccine was used for the first time.
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Pathology:
1. Acute stage
+oliomyelitis is a generalized infection which may involve the
whole body. ,otor involvement of the spinal cord and brain stem is the
only permanent manifestation
a" #ollowing $ultiplication in the pharyn% and intestine& the virus
penetrates the intestinal wall and travels in blood to all body parts. -o,
viral multiplication plays a ma.or role in the neural damage.
!" 'n 1( to 5( of the affected persons& the virus invades the spinal cord,
where it has a predilection for motor neuron in the anterior horn cells
/0123, causing a variable degree of paralysis. Then, cells either die or
shed the virus and regain a normal morphologic appearance.
c" )reas in which lesion $ay occur include:
- -pinal cord, especially the anterior horn cells; though to a lesser extent
the intermediate and dorsal horns.
- ,edulla, including the cardio-respiratory centers.
- 2erebellum, midbrain, thalamus and hypothalamus.
- ,otor cortex.
d" The pathological changes consist $ainly of:
- 1yperemia and edema of the piamater /the innermost of the meninges3.
- ,inute capillary hemorrhage.
- +erivascular infiltration of lymphocytes /a variety of white blood cells3,
which bloc$ off the small blood vessels.
- +ressure exerted on anterior horn cells and interstitial tissue is most
stri$ing in the lumber and cervical enlargement of the cord.
e" The anterior horn cells show:
- 4issolution of mitochondria.
- +rogressive chromatolysis.
- -hrin$age of nuclei.
"
- 4egeneration of cell bodies, which extends to the axons.
- 4isappearance of the 012, to be replaced by sclerotic tissues.
- 2omplete degeneration of the interstitial cells.
f" )s the virus invades the central nervous syste$& the e%tent of
neurological and functional recovery is deter$ined !y the nu$!er of
$otor neurons which:
- 5ecover and resume their normal function.
- 5e-survive unimpaired.
- 4evelop terminal axonal sprouts to re-innervate muscle fibers.
2. Chronic stage
A. Locomotor system:
1. *uscles:
a3 4estruction of the 012 causes a variable degree of paralysis, ranging
from minimal degree which may recover completely, to severe degree.
b3 The lower limbs are usually more involved than the upper limbs.
+ertain $uscle groups tend to !e $ore often involved than other groups.
These groups include: 1ip and $nee extensors, an$le dorsiflexors,
intercostal muscles, spinal muscles, thenar muscles, deltoid and triceps.
c3 The paraly,ed $uscles show 0trophy, fatty infiltration and
replacement by connective tissue. 2ontractures may occur due to partial
or complete fibrosis of the paralyzed muscles. -econdary contractures of
ligaments and .oint capsules may result from long-standing shortening of
muscles and tendons.
-. Bones and .oints:
- The lac$ of muscle pull in addition to vascular and neurological causes
resulting from the effect of paralysis, lead to shortening in the length and
diameter of bones in the growing limb. 6ractures may also occur.
#
- The effect of long-standing contractures on the .oint surfaces may cause
them to become deformed and subluxated or dislocated.
- 7nsupported wal$ing on wea$ .oints may also lead to some changes.
- Intra-articular adhesions may form if attempts are made to straighten the
.oints by vigorous manipulations.
B. Skin an su!cutaneous tissues:
+aralyzed limbs may become edematous in cold climates due to
hemostasis /stagnation of blood in its vessels3 and gravity.
C. "es#iratory system:
8ung infections are common due to paralysis of the respiratory
muscles /diaphragm and intercostal muscles3.
D. Bul!ar $meulla% #alsy:
9ulbar paralysis usually recovers with no residual effects. 9ulbar
palsy in the acute stage may result in lung abscess in the chronic stage
due to the inhaled secretions.
Causes of eformities:
1. *uscle spas$:
The initial cause of deformities in polio appears to be muscle
spasm, followed by interstitial fibrosis and collagen deposition in paretic
muscle groups. The exact cause of muscle spasm is un$nown but it
appears to be due to in-coordinated involuntary contractions of the
surviving fibers in the partially paralyzed muscles.
-. /ffect of gravity:
:ravity may lead to e;uinus of the an$le and adduction of the
shoulder.
(
0. /ffect of posture:
+rolonged bed rest, particularly in severely paralyzed patients
without ade;uate physical therapy may cause flexion deformity of the
hip, $nee and an$le .oints. This is the commonest deformity in
poliomyelitis patients after muscle imbalance.
1. hort leg and other associated defor$ities:
0 short leg or a flexed hip may cause the pelvis to tilt and a
compensatory scoliosis in the spine. If this deformity is left uncorrected,
it may become permanent.
5. 2eight !earing on weak .oints:
This may lead to genu recurvatum or valgus an$le. The deformity
becomes worse with stretching of the ligaments or the .oints without
external support to the deformed .oint.
3. 4rogress of contractures:
0ll the mentioned deformities may progress if left uncorrected in
children where bone growth is not e;ualized. 7ntreated mild spinal
deformity may lead to severe and permanent scoliosis or $yphosis.
Common eformities:
a" 5ip .oint: 6lexion, abduction and external rotation is the commonest
deformity due to relative wea$ness of the opposing muscle groups.
!" 6nee .oint: The commonest $nee deformities are flexion deformity
due to paralysis of the $nee extensors and mild valgus deformity /#*<3.
:enu recurvatum may occur due to early weight bearing on a wee$ $nee.
8ateral rotation of the tibia on the femur and lateral subluxation of the
$nee may also occur.
c" )nkle .oint: !;uinus deformity due to wea$ dorsiflexors is a common
deformity. =algus, varus and cavus foot are other commonly occurring
deformities.
)
Causes of muscle &eakness in #oliomyelitis:
Direct causes $'iral infection%:
1. +ermanent destruction of the motor cells with subse;uent atrophy and
paralysis of the denervated muscle fibers.
". Temporary and reversible impairment of nerve cell function due to an
inflammation or pressure.
(nirect causes:
1. /arly:
- 5eflex inhibition of muscular activity due to pain.
- Impaired muscle cellular function from nutritional and metabolic
disturbance.
-. Late:
- Insufficient exercise as a result of immobilization.
- !xcessive activity or over-stretching of a wea$ened muscle.
- +ersistent limitation of motion due to contractures and shortening.
- 1abitual positioning and muscular imbalance.
- +ersistent reflex inhibition of muscular activity, as a result of prolonged
and sustained activity of antagonistic musculature.
Vaccination:
There are two types of polio vaccines:
a" alk vaccine:
It is composed of $illed viruses, given by in.ection. It has the
advantage of being safe and not being suppressed by the intestinal
entroviruses. -al$ vaccine has the disadvantage of
> The need for repeated in.ections.
> 4elayed immunity as it needs about three wee$s to achieve.
?
> Incomplete immunity.
!" a!ine vaccine 7trivalent vaccine":
It is composed of attenuated live polioviruses. It has the
advantages of having faster immunity within about three days and longer
immunity, which may be long-life. It has the disadvantage of being
prevented from action by the intestinal entroviruses. Three drops of the
-abine vaccine are to be administered into the bac$ of the mouth or on a
lump of sugar. 4osage should start at the age of two or three months, to
be repeated three successive times at (-? wee$s interval. 0 booster dose
at the age of 1& months and another dose at school entry are also
re;uired.
Clinical features:
Initial incubation period, which varies from seven to twenty one
days, is the common interval between infection and the clinical illness.
)fter the incu!ation period& four responses $ay occur:
1. )sy$pto$atic polio: This can only be diagnosed during an epidemic or
if the virus is cultured from the stool.
-. )!ortive polio: There is a flu-li$e illness with fever, nausea, vomiting,
sore throat, headache and constipation. The virus may also be cultured
from the stool.
0. 8on9paralytic polio: Three or four days after the above initial
symptoms, the patient may develop a stiff nec$. ,oreover, deep and
superficial reflexes are usually depressed. Temporary urinary retention
and constipation without sensory loss may follow.
1. 4aralytic polio: The signs and symptoms in paralytic polio are very
variable in both duration and severity. 0fter few days from paralytic
polio, the lower motor neuron paralysis develops. The distribution of
%
paralysis is asymmetric and patchy. 0ccording to the affected area, three
forms are found
a" pinal for$: It may affect any group of muscles from the nec$, trun$
or limbs including the diaphragm. In addition, there may be transient
involvement of the bladder with the subse;uent urinary retention.
!" Bul!ar paralysis: The motor nuclei of the cranial nerves may be
affected with or without involvement of the vital centers. The most
important sign of bulbar paralysis is the inability to swallow /dysphagia3
due to pharyngeal paralysis. In addition, the patient cannot cough
properly due to paralysis of the larynx.
c" /ncephalitic for$: There will be some degree of motor paralysis in
addition to drowsiness, disorientation, mental disturbance and even
comma may occur.
)reatment:
1. Acute stage
+aralytic stage of poliomyelitis is always preceded by the
prodromal or pre-paralytic stage. Treat$ent during this stage includes:
- @bligatory rest in bed.
- ,aintain fluid and electrolyte balance.
- !xhausting examinations are contraindicated.
- 2omfortable and relaxed position should be carried out.
- ,inimize muscular pains during handling.
- 0void in.ection and non-emergency operations.
- 2are of s$in to avoid bedsores.
- 4aily breathing exercises to avoid respiratory infection.
)t the i$$ediate post9acute stage& concentration should !e directed to:
- !ncourage periods of near-normal body alignment within limits of pain.
- 7se moist heat when the patient is afebrile to relieve muscle spasm.
&
- 6orty-eight hours after the patient is afebrile, range of motion and
gentle stretching exercises should be applied daily.
- ,aintain correct posture and avoid any possible deformity using
pillows, footboards and splints.
- 0s tightness and resistance to movement subside and muscle balance is
gained, progressive sitting and weight-bearing exercises are re;uired.
2. Con'alescent stage
0s there is decreased capacity for wor$, energy expenditure should
be decreased to the lowest possible level to prevent over-exhaustion.
a" :ange of $otion e%ercises:
They aim to prevent contractures. This can !e achieved !y:
- +assive movement within the limits of pain.
- ,uscle stretching but avoid overstretching.
- 7tilization of splints and bracing to prevent deformities, assist function
and avoid undesirable substituted actions.
!" *o!ili,ation:
The patient should be out of bed early unless paralysis is very
severe. 1e A she should be exercised first in bed then in chair before
being stood up. Bal$ing aids can be used in this stage.
c" *uscle reeducation:
- Improve muscle strength of all muscles in the body.
- 6acilitation of wea$ and paralyzed muscles either by manual,
mechanical or electrical methods such as ;<uick stretching& tapping&
proprioceptive neuro$uscular sti$ulation 748#"& ice application&
faradic sti$ulation and vi!ration techni<ues=.
- 2oncentration should be directed to obtain maximum strength of
appropriate muscle groups to compensate the action of wea$ muscles,
prevent substituted action and prevent deformity.
'
- 0void excessive exercises to prevent muscle exhaustion, fatigue,
undesired movement and energy loss.
d" '$prove$ent of respiration: If respiratory paralysis occurs, the role of
physical therapy is essential to $eep the lungs free. If the patient cannot
cough properly, breathing exercises and postural drainage may be used.
*. Chronic stage
a" '$prove functional activity:
- @verdevelop residual abilities to substitute for lost motions.
- Increase proprioceptive awareness through repetitive practice.
- Improve strength of the remaining muscles by high resistive exercises.
- The use of supportive devices is indicated.
- -urgical procedures are utilized to regain motion and correct deformity.
!" *anage$ent of li$! shortening:
- Treatment of leg shortening should be conservative in most cases.
- -hortening of one cm re;uires no treatment, while more shortening
re;uires compensation through the use of medical shoes or braces.
c" /lectrical sti$ulation:
0s poliomyelitis disappeared altogether from !urope and most of
the well-developed and advanced industrialized countries, there is no
international literature concerning management of poliomyelitis since
1'?*
s
. 7nfortunately, as such infectious disease still exists in a large
proportion of many poor countries; discussion of the new methods for
treatment of poliomyelitis is undoubtedly fruitful.
:alvanic current 7a long9width sti$ulus& $ore than 1>> $sec" is
able to stimulate denervated muscle fibers, having resting membrane
potential of /-'* mv3, which is higher than that of the nerve /-%* mv3. 0s
poliovirus affects motor neurons unselectively, a single muscle may have
some affected and some spared muscle fibers. -o, galvanic current will
1*
then stimulate both the denervated and innervated muscle fibers.
!xcessive stimulation of innervated muscle fibers leads to their fibrosis.
@n the other hand, the use of faradic stimulation /a short9width
sti$ulus& less than 1>>9$sec width" will enhance activation of the
recovering fibers whose nerve cells were compressed. 6aradic
stimulation can also help in improving the muscleCs general condition and
accelerating development of functional abilities in both convalescent and
chronic stages of poliomyelitis.
d" ?i!ration:
The use of vibration in the treatment of poliomyelitis has not been
tried before because poliomyelitis as a disease disappeared completely
from many countries, in which scientific researches concerning
neurophysiology are well advanced. 0mong aims of physical therapy
applications are to activate partially affected muscles and to give the
patient the feeling of movement and posture. It is also important to
increase afferent impulses to the motor neurons by increasing the area
and receptors stimulated.
0ccording to the neurophysiologic mechanism of vibration,
vibrator is an excellent tool for increasing the amount of afferent
impulses toward motor neuron pool as it is the most effective stimulus to
Ia nerve fibers, which has a direct contact with motor neuron pool.
4uring application of vibration, the patient should be relaxed and muscle
fibers to be vibrated are fairly stretched.
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